Diagnosis and Management of Cirrhosis and Its Complications

Abstract

ImportanceCirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people.ObservationsThe most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men.Conclusions and RelevanceApproximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.

Diagnosis and Treatment of Cirrhosis—Reply

“…For example, lactulose therapy improves sleep for patients with covert hepatic encephalopathy . Following the publication of our Review, we showed that many patients with cirrhosis experienced improved sleep with use of lactulose even if they had not been diagnosed with hepatic encephalopathy …”

“…In Reply Dr Braillon makes multiple important points about the recommendation of using hydroxyzine for sleep in patients with cirrhosis. Our Review focused on evidence-based therapies for patients with cirrhosis, and unfortunately, to date, trials of specific nonpharmacologic therapies for sleep disorders in the context of cirrhosis are lacking. However, in a recent article about contemporary management of pain in cirrhosis, we recommended nonpharmacologic interventions for sleep disorder.…”

“…However, drug interactions are not known for contemporary agents. Interactions between terlipressin and hydroxyzine were also raised, but inpatients with hepatorenal syndrome were not the intended population for sleep disorder therapies in our Review …”

Announcing Expanded Content for Clinicians Through the Clinical Review and Education Section at JAMA Internal Medicine

“…We plan to cover a broad range of topics relevant to internal medicine, such as substance use disorders, obesity, and dementia. These reviews will follow a format similar to that of other JAMA Network journals; for example, a recently published review on the management of cirrhosis and another on treatment strategies for symptoms of menopause …”

Diagnosis and Treatment of Cirrhosis

“…To the Editor I believe that the recent Review about the diagnosis and management of cirrhosis wrongly promoted off-label use of hydroxyzine in its abstract by mentioning “[t]rials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction….”…”